Alcohol habits. None or seldom (-6); moderate with less than 2 beers or 8
ounces of wine or 2 ounces of whiskey or hard liquor daily (-12 – if you
consider current research, +6 if you follow this older chart); heavy, with
more than above (+24)

Eating habits. Drink skim or low-fat milk only (-3), eat much bulky food (-3), heavy (3 times a day) meat eater
(+6); more than 2 pats of butter daily (+6); more than 4 cups coffee/tea/cola daily (+6); usually add salt at table (+6 but is in
dispute).

Auto driving. Regularly less than 20,000 miles annually, and always wear seat belt (-3), regularly less than 20,000 but
not always seat belt (0), more than 20,000 miles (+12)

Drug habits. Use of street drugs (+36)

TOTALS – Part one

Physical Inventory

+

-

Weight. “Ideal” weight at age 20 was ______. If current weight
is more than 20 pounds over that, score (+6) for each 20 pounds. If same
as at age 20 , or less gain than 10 pounds (-3)

Blood pressure. Under 40 years, if above 130/80 (+12); over 40 years, if
above 140/90 (+12).

Cholesterol. Under 40 years, if above 220 (+6); over 40 years, if above 250 (+6)

Heart murmur. Not an “innocent” type (+24); with history of rheumatic fever (+48)

Pneumonia. If bacterial pneumonia more than three times in life (+6)

Asthma (+6)

Rectal polyps (+6)

Diabetes. Adult-onset type (+18)

Depressions. Severe, frequent (+12)

Regular* medical checkup. Complete (-12), partial (-6).
* Regular refers to healthy people who have thorough medical exams at the following frequencies, according to age: 60 and up,
every year, 50 – 60 every 2 years, 40 – 50, every three years, 30 – 40, every 5 years, 25 – 30, as required for jobs, military, etc.

Regular dental checkup. Twice
yearly (-3)

TOTALS – Part Two

Family and Social Inventory

+

-

Father. If alive and over 68 years, for each 5 years above 68 (-3);
if alive and under 68 or dead after 68 (0); if dead of medical causes (not
accidental) before 68 (+3).

Mother. If alive and over 73 years, for each 5 years above 73 (-3); if alive and under 68 or dead after 68 (0); if dead
of medical causes (not accidental) before 73 (+3).

Marital Status.If married (0); unmarried and over 40 (+6).

Home location. Large city (+6), suburb (0), farm or small town (-3).

TOTALS – Part 3

For Women Only

+

-

Family history of breast cancer. In
mother or sisters (+6)

Examines breasts monthly (-6)

Yearly breast exam by physician (-6)

Pap smear yearly (-6)

TOTALS – Part 4

Score

+

-

TOTALS – Part 1

TOTALS – Part 2

TOTALS – Part 3

TOTALS – Part 4

TOTAL – Chart

Current
age

Divide chart total by 12 and enter with + or - .

Add or subtract the above figure from your current age for your MEDICAL AGE.

Adapted by the Center for Health Education, Blue Cross and Blue Shield of Greater New
York Center, from How to Be Your Own Doctor… Sometimes by Keith W. Sehnert, M.D.,
with Howard Eisenberg, Grosset & Dunlap, 1975.